New guideline on children's concussions could influence clinical practice around the world

A newly published guideline on the diagnosis and management of mild traumatic brain injuries (mTBI) in children is expected to influence the clinical care of concussions around the world, says the lead of the University of Calgary’s Integrated Concussion Research Program, Dr. Keith Yeates, PhD. 

Yeates — head of the Department of Psychology and member of the Alberta Children’s Hospital Research Institute and the Hotchkiss Brain Institute at the Cumming School of Medicine (CSM) — was a co-lead author on the report, initiated by the U.S. Centers for Disease Control and Prevention (CDC). 

The CDC guideline was based on a systematic review of 25 years of literature on the diagnosis and management of children’s concussions. It consists of 19 clinical recommendations that cover diagnosis, prognosis, management and treatment. The systematic review and guideline have been published online by the prestigious paediatric health journal, JAMA Pediatrics. In creating the guideline, CDC scientists and leading experts in the field undertook the most extensive review on the science of paediatric mTBI diagnosis and management to date. 

"The goal in developing the guideline was to help improve and standardize care for kids with these injuries, not just in the United States, but hopefully, worldwide," says Yeates, also an adjunct professor in the departments of clinical neurosciences and paediatrics at the CSM. 

Because their brains are growing, children are more vulnerable to the changes in brain function that happen as a result of a concussion. In a recent CDC study, about 2.5 million high school students in the U.S. reported having had a sports-related concussion within the past 12 months. More than 800,000 children seek care for concussions in U.S. emergency rooms each year. 

Among the 19 practice-changing points of the guideline was a recommendation against the routine imaging of patients through MRIs, CT scans, skull radiographs, and other imaging methods. 

"In the vast majority of cases, kids with concussions don't show visible lesions on standard imaging," notes Yeates. "There is no data to suggest that standard imaging differentiates kids with concussions from kids with other types of injuries, or even healthy kids." 

The CDC guideline also advocates the use of age-appropriate symptom scales to diagnose concussions, and urges patients to return gradually to non-sports activities after no more than two to three days of rest. 

“We’ve discovered that the old advice, that kids should rest until they’re asymptomatic, is actually counter-productive,” says Yeates. “Yes, two or three days of rest makes sense, but pretty quickly we should start encouraging kids to begin engaging in light activity, and then as they tolerate it, aerobic activity.” 

He continues: “We know that exercise actually facilitates recovery from brain injury and it’s generally good for the brain. The key issue has always been timing and we’re finding more evidence that prolonged rest can actually be harmful. All it does is decondition children physically, disconnect them socially, and make them distressed psychologically. Children generally do better when they get back to their activities on a reasonably quick basis.” 

The government report also suggests that patients should be provided with instructions on returning to activities that are customized to their unique symptoms. Further, health-care professionals should screen patients for risk factors that could affect outcomes after a concussion. 

“There are three sets of factors which have been identified as important in concussion recovery,” says Yeates. “One is the severity of the injury itself. Two is what the child brings to the injury, such as, for example, having ADHD, or a prior concussion, or a history of migraines. Three is the environment. The family, the community, the school — these can all contribute to a child’s recovery.

“Each of these factors should be taken into account.” 

Yeates also stresses that while each child’s recovery follows its own trajectory, it is important to make families aware that 70 to 80 per cent of children with concussions do not have significant difficulties that last more than one to three months after their injury. 

“That’s an important takeaway,” Yeates says. “What sometimes gets lost in the media message is that, yes, we have to be concerned about concussions. We have to take them very seriously. But the majority of children are going to get better. Let’s try to reassure families of that.” 

Led by the Hotchkiss Brain Institute, Brain and Mental Health is one of six research strategies guiding the University of Calgary toward its Eyes High goals. The strategy provides a unifying direction for brain and mental health research at the university and positions researchers to unlock new discoveries and treatments for brain health in our community. 

Community donations through the Alberta Children's Hospital Foundation support the Integrated Concussion Research Program and research conducted by Dr. Keith Yeates at the University of Calgary.